Lamar County & District Attorney Commercial Fraud Form-179

119 N. Main, 3^rd Floor | Paris, TX 75460

903-737-2413 | fax: 903-737-2455

www.lamarcountyattorney.com

Maker of Check:

Home Address: ( )

Street City State Zip Phone

DL# DOB Gender (circle) M F Race ____________

Did you Contact the Bank? Remarks:

Have you contacted signer? How?

Money collected should be sent to: ( )

Street City State Phone

Check given for (circle): Cash Salary Merchandise Loan Past Rent Services Other:

Person who took check from maker :

( )

Street City State Zip Phone

CIRCLE ONE:

• Can person who took check identify maker in Court? YES NO
• Was check passed in Lamar County? YES NO
• Was a partial payment taken on check? YES NO
• Was this a stop payment check? YES NO
• Was this a post-dated or held check? YES NO

Disbursements are done on paid checks twice a month LIST CHECKS:

$

$

$

$

$

Your Name :

Total: $

Remarks :

Note: The County Attorney’s office cannot legally prosecute checks taken outside Lamar County, payments on charge account, and post-dated checks.

PLACE CHECK HERE